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Tuesday, February 18, 2014

MiM Mail: From a doctor in physical therapy

Please bear with me
through the beginning of this post, but I feel the background is
pertinent. I'm not exactly sure where to start. I am 33 years old, a
wife to a military officer, a mother of a precious 4 month old son, a
doctor of physical therapy, and an endurance athlete.

When I was younger, I spent 4 years in the Air Force as an aerospace
physiology instructor. I completed my A.A.S. in Aerospace Physiology
Instruction through the Community College of the Air Force, and my hard
work and high performance was recognized numerous times and at various
levels through awards, such as the junior enlisted member of the quarter
and year. My flight commander felt that as an enlisted member, I would
never reach my full potential, so he encouraged me to separate from the
military to complete my degree. I followed his recommendation,
separated from the military in 2005, and took the remaining classes
required to complete a B.S. in Biology. I remember studying for a
biochemistry final, looking up at a poster that read "Physical Therapy-
We're Hands On," and thinking that might be an interesting profession to
look into. I shadowed with a home health PT who LOVED her job after
20+ years, then worked as a physical therapy technician in an outpatient
orthopedic clinic for several months. I educated myself on the
profession, read the APTA's Vision 2020 about how the physical therapy
profession was moving towards direct access, autonomy, lifelong
learning, and educational programs were now doctorates. My
undergraduate GPA was good, but not stellar, so to demonstrate my
ability to succeed academically, I completed a rigorous M.S. in Biology
while concentrating my studies in neuroscience, cell and molecular
biology, graduating with a 4.0 GPA. I scored the highest in all of my
classes- in fact my pharmacology professor wrote a note on one of my
exams thanking me for scoring so well because after grading my
classmates, she was beginning to think she was failing at teaching. My
hard work paid off- I was accepted to the University of North Carolina
at Chapel Hill Doctorate in Physical Therapy program.

Fall 2008 I
started my doctorate. About a month into the program, I noticed I
wasn't as interested in the physical therapy coursework as I was in the
pathology or pharmacology classes. I missed the "science" I had loved
so much during my masters... This trend continued. I began thinking
about medical school, but had committed to physical therapy and thus
felt I needed to give it a chance. 2010 I bought an MCAT book, but
again talked myself out of it. Student loans were piling up- did I
really want to increase those? 2011 I graduated and began working as a
physical therapist. I spent over $4500 in continuing education that
year in an attempt to find something I liked in PT: lymphedema, manual
therapy, vestibular therapy, biomechanics of running, treating the
multisport athlete (these last two were very interesting, especially
since I am a triathlete), etc. I am a very positive attitude person,
yet have found very little in PT that I love besides being a clinician
and working with patients. My masters research involved
neuroelectrophysiology on CA3b neurons in the hippocampal formation and
very little human contact- although I loved the research, I missed
working with people (and my PI never spoke to me).

I thought becoming a doctor of physical therapy would enable me to
teach (which I love), but most universities require a "terminal degree"
such as a PhD or EdD. I thought direct access would allow patients to
walk into my office with acute injuries and I could treat them before
these injuries became chronic- well, not all states are direct access, a
lot of insurance companies don't pay without an MD Rx, and in some
states I can't even perform Grade V manipulations- something I am well
skilled in doing! Differential diagnosis was heavily emphasized
throughout my schooling and clinic work- I am able to recognize flags
that warrant a medical examination and referral to a medical doctor.
What is the point of the profession moving to a doctorate when, even as
doctors, we are so limited?

Fast forward to today. I think about applying to medical
school everyday. I read books on perinatal stem cells, biochemistry of
obesity, metabolic pathways, pathologies affecting the nervous system
and I get EXCITED!. I want to treat patients- not by teaching them how
to walk or improve muscle function- but I want to attack their diseases
at the cellular level! I want to physically excise tumors, shrink them
pharmacologically, and get involved in research. Yet, I hesitate and
question if this is practical. I have read several mothers in medicine
posts about burnout, disillusionment- would this happen to me? If I
apply and am accepted, my family will be supportive, but I will be
increasing my student debt (I already have $160K), taking time away from
spending time with them, and I'm certainly not getting any younger- am I
selfish in even wanting to become a medical doctor? If I become an MD-
or even an MD/PhD (I do love research), complete a residency, and
fellowship will I have time to spend with my family, continue training
and competing as a triathlete, or even just sit back and relax? Also,
my husband plans on spending 8-14 more years in the military before
retiring. I have spoken with PTs that became MDs and are now much
happier- but they have all been male. I have sought guidance from my
mentors from PT school- they encouraged me to stay in PT...

I was excited to find this blog! What thoughts do you all have? I
feel I need to make a decision- this contemplation has been going on
since 2008...

17 comments:

Well, it sounds like from a professional standpoint, you'd likely be happier as a physician (more autonomy, greater diversity of avenues to help "heal" patients), but given your personal circumstances, it sounds like it will be a huge sacrifice, so that is something only you and your husband can decide if it is worth it.

I am a pediatrician and was active duty for 7 years, so I think my personal experience helps me understand some of the challenges you will face. The biggest factor I see is co-location with your husband. I think you will inevitably be separated for many years if you pursue this, as you'll be someplace for med school for 4 years (you have some control over this, but to some extent are limited by where you are accepted), then you have a lot less control over where you go for residency because of the match system. The military is not going to take your job into account at all in your husband's duty assignments (they might say they will, but they don't, which you guys probably know with your combined active duty time, as I have so many friends that are even dual active military that still get stationed apart).

How old are you? Do you have kids now? How old are they? I think the biggest factor will be that you will be working insane hours during some of 3rd year, a little bit of 4th year, and all of residency. If you are geographically separated from your husband, this will make child care extremely difficult, unless of course they live with him. To me, that is your biggest issue (his military status).

However, you only get one shot at life, and if you have many years ahead of you to work, it may be worth having 5 of the next 7 years be very difficult if it means you will enjoy the rest of your years immensely more. The other thing you have to weigh is whether you will be able to enjoy those later years with massive debt. I can't live with debt (hence the military), so I couldn't do that. Have you thought about the HPSP program? Then the military would pay for your med school and you'd be more likely to be able to co-locate with your husband?

Thank you for your response. I am 33 and have a 5 month old son. We would like to try for another one after I complete an insane canoe race in June 2015.

I think you hit one of my major concerns right on the head: co-location with my husband (or lack thereof). CONUS would be one thing, but what if he is overseas? I will definitely look into the HSPS program.

With respect to my debt, one of my MD, PT mentors said he and some other PTs that went to medical school, were able to pay for medical school without debt by working a few weekends a month as PTs (while in school). Alternatively, my husband has suggested signing over his GI Bill to me for medical school... but I think he should sign it over to our son.

I second Katherine Koss' comment. The HPSP sounds like a good program.

I am 32 (will be 33 later this year) and have been accepted to medical school. I don't know if I would have been brave enough to tackle medical school with existing debt. I recommend going to the AAMC's website and using the MedLoan calculator to figure out what you'd face after graduation.

As for the current debt, is it all student loans? Will you be able to defer payments? Are they federal loans? There is a cap on the amount of federal student loan debt you can hold. Will that be a factor? I would attempt to pay off as much of the debt as possible, even if it means delaying your medical school application a couple or more years.

I say go for it, but consider how you'll juggle child care, co-location and debt very carefully. Good luck!

The large debt I posted is all student loans- I call them my "beach house." Most of the payments can be deferred while in school, but my husband and I can continue to pay them off if I go to medical school. I will look into the MedLoan calculator- thank you for suggesting that resource, I didn't know it was available. As in my reply to Katherine, I do know of several PTs that worked some weekends to put themselves through medical school debt-free. That would take time away from my family and studying, so we would have to really discuss what our priorities are.

Do you have children? How are you adjusting to medical school life? What about your tactics for balancing school, home life, hobbies? What did you do before medical school?

Just the other day I was thinking that even though I love my job as a family physician, if I had a second choice it would be physical therapy. My 5 month old daughter was born with tuberous sclerosis and we have her in early intervention as she is at significant risk for developmental delay. The physical therapist who comes every month is absolutely wonderful and a miracle worker. I think of the major impact his skills have on so many childrens' lives and what a rewarding career that would be.

In many instances physical therapy can cure an underlying problem that people might see a physician initially for. As a primary care doc I see many chronic pain, back pain and other issues that I can prescribe a pain medication for but that doesn't really fix the problem. In the end, if people are diligent with physical therapy it can really make a huge impact in their quality of life. Same goes for older patients at risk of falls, etc.

The way I see physical therapy is that it is a healing profession just like medicine is, without as much liability and without the ability to prescribe narcotics - a huge headache. Anyway I hope that helps. I'm sure you know all of this already. Others have touched on the debt load and other considerations - I just want you to know that PT can have as much impact on peoples' lives as medicine can, if not more in many cases. Best of luck in your decision making!

I read your post. You are extremely well educated. Then I read $160K in debt. Besides doing the military scholarship, I'm not sure that you wouldn't be suffocated by your debt unless you get a full medical school scholarship. Woooohhhh. $160K and not even in med school. I can't see beyond that . . . .

What premed classes do you need to take? Just the MCAT? Why not take it and see what you get? If you can do military scholarship or get a full scholarship and you are SURE you want it, go for it.

I second the concern about the debt. You really have to think twice about incurring so much -- I couldn't imagine doubling (or more) that figure. I've been practicing medicine for 10 years and I'm really not sure it is worth it. Other ideas are going to PA degree, which is less schooling but may be able to get you where you want to go without so much of a time commitment or debt.

I think you're idealizing medicine. Your ideas about what you'd do in medicine fall into about three different specialties. Reading this and other blogs, I get the sense that a lot of medicine doesn't involve talking or working with patients, but doing paperwork and using knowledge to write orders that other people will carry out. Most physicians don't work in research, either. And most physicians don't cut out tumors or whatever, but work with people about diabetes, heart disease, obesity, birth control, arthritis, depression, a lot of stuff that really depends on someone else (the patient) doing something. (Like PT, I'd guess.)

I think specialist physicians will tell you that insurance doesn't allow patients "direct access" to them often, either, but that they depend on referrals from other physicians.

How close to finished with PT school are you?

The debt is already overwhelming to me, but I have no idea how much PTs make on average. I do have a sense that PTs can work pretty much anywhere, so you could move for your husband's career if you want to?

Like Emily above, I think the people who've worked with me to PT a back problem and a foot problem helped me solve the problems way more than giving me some drug could have.

Bardiac, thanks of your response. I will have to think some more about this idealizing medicine concept- I'm not sure I considered it.

I completed PT school in 2011, and have been practicing since then. PTs CAN pretty much work anywhere, we just have to apply for license by endorsement for each state we wish to practice in. That makes it a handy profession to have with a husband who moves frequently. In the past year I have moved from NC to FL to TX due to my husband commissioning and new assignment because of it. We will be in TX for 2-4 years.

One other thought, the Uniformed Services med school? Your salary, even while a med student there, could really put a dent in your current student debt load, and you wouldn't incur any more debt. Plus, I think there is a decent chance they'd station your husband in DC while you were in school since there are so many different bases nearby. Being dual active duty military will be your best shot at co-location. Downside is that then you'll owe 7 years of active duty, rather than the 4 of HPSP, but if your husband is staying in until retirement and you already have 4 years of service yourself, it might not be a bad choice. No new debt, pay off old debt, and you'll both get a really nice retirement + healthcare after 20 years of active duty service. You guys know yourselves and the military well enough to know if this would be a good fit for you. I think in your circumstances, that might be my choice. As for balancing kids + medicine, you can get lots of opinions on that here. I think it is probably easiest to either have kids that are 3 or older by the time you are a 3rd year med student or have kids after residency since having babies/toddlers is the hardest during 3rd year of med school and residency, but lots of people manage to make that work too. Best of luck in whatever you decide!

Maybe you should look into doing a PhD and doing research in addition to continuing some clinical work. Academic centers LOVE researchers and it sounds like you have a real interest and passion for it. 160K in debt is already massive, and piling on to that by doing med school in my mind is not advisable unless you get med school paid for another way. That kind of debt becomes such a significant burden when you're trying to embark on your 2nd career.

I really think you should shadow some docs or find a way to get a better idea of the real day to day work of a physician. I am a big encourager of those who legitimately want to go to med school no matter what the situation, however, the typical post med school debt is nearly 200K or something. I would say that in order to pursue this you should have a plan that allows you to incur no additional debt. Given the amount of training ahead you would not be in a position to begin paying any of your debt in any real way for 8-12 years.

Also, your description of your intellectual reading interest don't really sound like topics that necessarily even correlate with the actual practice of being a medical doctor and would only be very minimally addressed in medical school. Those topics sound fascinating to me as well but I draw no correlation between those interest and a medical school as a whole to be honest. The scientific knowledge that you have gained about the inner workings of the body are likely more extensive as a Doctor of Physical Therapy.

I love my career choice. I love patient care and surgery and surgical research, this is an amazing field that fits me. I think you need to do a little more research about the actual practice of medicine and what portion of it will actually address the things you are interested in before you commit. You have to decide if its worth all the other non-patient care annoyances and other red tape in order to gain the experience you describe.

Cutter, thanks for sharing your thoughts. A plan to avoid additional debt is definitely a high priority!!

I want to be able to treat the whole patient- or have the ability to refer directly to the appropriate specialty to treat areas I am not able to personally treat (without calling a physician every time and "suggesting" this may be the appropriate route). As a PT, I am pretty limited to the musculoskeletal system, and even within the MSK system there are limitations. I can use special tests to make a rehab diagnosis, but I can't order X-rays or MRIs. If a patient comes to me with plantar fasciitis and would benefit from iontophoresis, I can't start this treatment until I receive an Rx for dexamethasone from a physician. If I think a medication would be helpful to control pain, I can't prescribe it. Those are just a few examples, I have many more.

I will do more research on the practice of medicine and how it addresses my interest- thank you for the recommendation. I have spent several days shadowing orthopedic surgeons in clinic and in the OR, observing a subscapularis repair and a total knee replacement surgery in the OR. I have also spent clinical time with neurologists who worked with patients diagnosed with MS. Before we saw the neurology patients, we reviewed their MRIs and compared with previous imaging when available. I took the patients history and completed the physical exams, reporting my findings to the neurologist, then the neurologist and I saw the patients together to address their needs/questions, alter medications, provide education, and make referrals when appropriate. One patient experience in particular sticks out in my mind. She had been diagnosed with relapsing-remitting multiple sclerosis 10 years ago, and the disease modifying medication had slowed progression. Her main concerns were mobility, and urinary incontinence. She had stopped going to visit friends because she was afraid she would not be able to control her urination while sitting on their couch. The neurologist was able to address all of these things during her visit: MRI to verify there were no new lesions in her brain or spinal cord, refer to PT for mobility, and order urodynamic testing (which I was later able to observe). In essence, the neurologist was able to "treat the whole patient."

As a former occupational therapist and now a first year medical student, I understand your feelings of discontent with the rehabilitation services realm of healthcare. I too discovered I was much more interested in the physiology of medicine than other aspects. Personally, I am very happy that I have started on my path to this career switch in the midst of motherhood, and thus far medical school has been exactly what I was hoping it would be. I agree with previous posters that the amount of debt you accrued during PT school is a hindrance. However, there are options available. For example, my school in the Midwest provides tuition + stipend for students who choose primary care fields and serve less populated areas. Good luck with whatever you decide!

KC - this is such a tough and major life-altering decision. It is really a loooonnnng hard road to go through and the reality is it definitely is harder for women, especially those with children. It will be a huge burden on you and your husband financially and unless your husband is a saint will likely cause marital stress as well. Being a military wife myself, I also understand the added complexity of your husband's career and future moves which might end up causing you to be separated geographically....Although I am happy to be in medicine (I'm in my final few months of residency) - if I were in your position I am not sure I could/would do it. It really is a personal decision but make sure you and your husband have some long talks about it. Best of luck with your decision!

I think it all comes down to priorities in life and how important life-work balance is to you. I am 33, a new military spouse, and a doctor but I am foreign trained. Hence I am considering all my career options at the moment all over again - toying with retraining in the US, pursuing a career in research or in pharmaceuticals or public health. For me, being separated from my husband is just not an option. We want to start a family, and I gave up my country friends, job and family to create a life with him. Don't get me wrong, I loved my job. I love medicine. But those thoughts have all been new to me - I completed a science degree and fell in love with physiology, biochemistry, pharmacology. That, along with my desire to do clinical work prompted me to apply to medical school. For years I have always had private thoughts that if given the choice I wouldn't do it over again due to all the personal sacrifices, impact on friendships, relationships, my own health. It was only when I finally finished 13 years of study in 2011 and I was able to be my own boss and I had a balanced work-life balance, I started to appreciate it. But it took that long. Now, I want to desperately have my career that I worked so hard for, so its not all wasted, and I'm still struggling with my choices on a daily basis so I haven't got it all figured out. My point is, medicine is a long journey, and you really should look into the entire process in detail BEFORE you embark on this. Research residency training programs and options for part time work with kids. Talk to your husband about long term plans. If anyone says you can have it all (family, life balance, quality time with your husband) they are probably saying this from the other side of residency and school. Because, I can tell you honestly with a empathetic heart, you won't be able to have it all until then. If you believe dedicating 7 years of your life to medicine at the cost of all else, will in 20 years time make you happy go for it. You don't want to live with regret in life, so trust your heart. Either choice will have consequences, and will involve sacrifices. One last piece of advice - if you start on the medicine train it will go full steam ahead. But you can always get off, remember that, despite what people around you say. I hope this site helps you make the right decision for this time in your life, one step at a time.

Mothers in Medicine is a group blog by physician-mothers, writing about the unique challenges and joys of tending to two distinct patient populations, both of whom can be quite demanding. We are on call every. single. day.

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